Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021

Importance: Before and during the COVID-19 public health emergency (PHE), commercially and publicly insured children may have faced different challenges in obtaining consistent and adequate health insurance. Objective: To compare overall rates, COVID-19 PHE-related changes, and child and family characteristics associated with inconsistent and inadequate coverage for publicly and commercially insured children. Design, Settings, and Participants: This was a cross-sectional study using nationally representative data from the 2016 to 2021 National Survey of Children's Health of children from age 0 to 17 years living in noninstitutional settings. Exposure: Parent- or caregiver-reported current child health insurance type defined as public or commercial. Main Outcomes and Measures: Inconsistent insurance, defined as having an insurance gap in the past year; and inadequate insurance, defined by failure to meet 3 criteria: (1) benefits usually/always sufficient to meet child's needs; (2) coverage usually/always allows child to access needed health care practitioners; and (3) no or usually/always reasonable annual out-of-pocket payments for child's health care. Survey-weighted logistic regression was used to compare outcomes by insurance type, by year (2020-2021 vs 2016-2019), and by child characteristics within insurance type. Results: Of this nationally representative sample of 203 691 insured children, 34.5% were publicly insured (mean SD age, 8.4 4.1 years; 47.4% female) and 65.5% were commercially insured (mean SD age, 8.7 5.6; 49.1% female). Most publicly insured children were either non-Hispanic Black (20.9%) or Hispanic (36.4%); living with 2 married parents (38.4%) or a single parent (33.1%); and had a household income less than 200% of the federal poverty level (79%). Most commercially insured children were non-Hispanic White (62.8%), living with 2 married parents (79.0%); and had a household income of 400% of the federal poverty level or higher (49.1%). Compared with commercially insured children, publicly insured children had higher rates of inconsistent coverage (4.2% vs 1.4%; difference, 2.7 percentage points pp; 95% CI, 2.3 to 3.2) and lower rates of inadequate coverage (12.2% vs 33.0%; difference, -20.8 pp; 95% CI, -21.6 to -20.0). Compared with the period from 2016 to 2019, inconsistent insurance decreased by 42% for publicly insured children and inadequate insurance decreased by 6% for commercially insured children during the COVID-19 PHE (2020-2021). The child and family characteristics associated with inadequate and inconsistent insurance varied by insurance type. Conclusions and Relevance: The findings of this cross-sectional study indicate that insurance gaps are a particular problem for publicly insured children, whereas insurance inadequacy and particularly, out-of-pocket costs are a challenge for commercially insured children. Both challenges improved during the COVID-19 PHE. Improving children's health coverage after the PHE will require policy solutions that target the unique needs of commercially and publicly insured children.